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Resume Objectifs Les potentiels evoques auditifs (PEA) sont utilises pour confirmer, par un test objectif, le diagnostic de surdite de l'enfant. Cet examen necessite l'immobilite du patient. Nous proposons une alternative a l'anesthesie generale chez l'enfant de moins de huit ans par l'administration intrarectale de pentobarbital avant l'examen. L'objectif de cette etude est d'evaluer l'efficacite et la tolerance du pentobarbital. Materiel et methodes Il s'agit d'une etude prospective de 68 patients realisee dans le service d'ORL et de chirurgie cervicofaciale pediatrique de l'hopital Robert-Debre (APHP). Les PEA etaient enregistres au moment de la sieste. Prealablement, un suppositoire de pentobarbital etait administre a la dose approximative de 5 mg/kg. Resultats Les PEA ont ete realises dans de bonnes conditions d'endormissement chez 61 enfants sur 68 (89,7 %) avec un delai d'endormissement moyen de 36,1 minutes. Aucun effet secondaire n'a ete retrouve chez 84,1 % des patients. Conclusion La sedation par le pentobarbital est efficace et bien toleree. La voie rectale est facile d'acces, indolore, avec un debut d'action rapide. Cette technique permet d'eviter le recours a une anesthesie generale.

Resume Les manifestations respiratoires associees au reflux gastro-œsophagien sont frequentes et variees, qu'il s'agisse de toux chronique, d'asthme, de bronchites, de pneumopathies segmentaires ou non ; elles peuvent concerner aussi les voies aeriennes superieures (laryngites, sinusites, otites, stridor). Le probleme essentiel est de savoir quel est le role exact du reflux gastro-œsophagien dans la pathologie respiratoire observee : le reflux est-il la cause unique ou tout au moins primordiale, le reflux est-il secondaire ou aucun lien n'existe-t-il entre les deux pathologies ? Dans cette demarche, la pHmetrie de longue duree est l'examen de reference, mais il faut s'aider egalement d'arguments cliniques et d'un bilan pneumologique, afin d'eliminer les autres causes de pathologie respiratoire. Lorsque le reflux parait en cause dans la pathologie respiratoire, un traitement medical est entrepris comportant un prokinetique et un antisecretoire. Ce traitement est generalement efficace et les indications de la chirurgie sont exceptionnelles chez l'enfant.

To assess the results of inlay butterfly cartilage tympanoplasty in children.Before-and-after trial; follow-up duration, 26.6 +/- 19.9 months (mean +/- standard deviation).Tertiary referral center.Fifty-nine pediatric cases of tympanic membrane perforation.Inlay butterfly cartilage tympanoplasty was performed under general anesthesia according to the technique originally described by Eavey and modified by Lubianca-Neto (i.e., without any associated split-thickness skin graft).Percentage of perforation closures, surgical complications, preoperative and postoperative puretone hearing thresholds; the results of inlay butterfly cartilage tympanoplasty were compared with those obtained in a retrospective series of 29 underlay fascia temporalis myringoplasties.The 71% "take rate" of inlay butterfly cartilage tympanoplasty was not significantly different from the 83% take rate obtained with underlay fascia temporalis tympanoplasty (p = 0.23, chi test). The anatomic results were improved when the graft diameter was at least 2 mm larger than the size of the perforation (81% take rate) (p = 0.009, chi test). No iatrogenic cholesteatoma was observed. Pure-tone hearing thresholds were improved at 0.5, 1, and 2 kHz, and stable at 4 kHz. Hearing levels were not different from those obtained with underlay fascia temporalis tympanoplasty.Inlay butterfly cartilage tympanoplasty is a safe, efficient, time-saving, and easy technique of tympanoplasty in children. Anatomic results may be improved by associating a split-thickness skin graft and/or by trimming a tragal graft much larger than the size of the perforation.

Une laryngotracheoplastie avec quadrisection du cricoide est indiquee en cas de stenose laryngotracheale tres serree, elliptique, ou lorsqu’il existe des remaniements importants du cricoide. Elle consiste en une section des parois anterieure, laterales et posterieure du cricoide suivie d’une interposition cartilagineuse anterieure et/ou posterieure. Materiel et methodes Cette serie retrospective porte sur 25 enfants operes d’une laryngotracheoplastie avec quadrisection entre 1991 et 2001 dans le service d’ORL et de chirurgie cervico-faciale de l’hopital Robert Debre (AP-HP Paris). Deux techniques ont ete employees : en un temps, avec intubation prolongee d’une dizaine de jours (n = 6), ou en deux temps avec calibrage, sous couvert d’une tracheotomie (n = 19). Resultats Avec la technique en deux temps, le pourcentage de decanulation a ete de 89,5 % (17/19) apres la premiere intervention, et de 100 % apres reprise chirurgicale. Avec la technique en un temps, le pourcentage d’extubation a ete de 83,3 % (5/6). Discussion La laryngotracheoplastie avec quadrisection du cricoide permet d’obtenir d’excellents resultats respiratoires dans les stenoses laryngees severes en particulier lorsque la mobilite du plan glottique est diminuee. La technique en un temps est particulierement interessante avant l’âge de trois ans car elle diminue la morbidite liee a la tracheotomie.

Resumen Las manifestaciones respiratorias asociadas al reflujo gastroesofagico son frecuentes y variadas, tales como tos cronica, asma, bronquitis, neumopatias segmentarias o no segmentarias; asimismo, pueden afectar a las vias respiratorias superiores (laringitis, sinusitis, otitis y estridor). El problema fundamental consiste en conocer el papel exacto del reflujo gastroesofagico en la patologia respiratoria observada: ?es el reflujo la causa unica, o al menos primordial?, ?el reflujo es secundario?, o ?no existe ninguna relacion entre ambas patologias? En este proceso, la pHmetria de larga duracion constituye la prueba de referencia, si bien es necesario ayudarse igualmente de argumentos clinicos y de una valoracion neumologica, a fin de eliminar las otras causas de enfermedad respiratoria. Cuando el reflujo aparece como causa de este tipo de trastornos, se inicia un tratamiento medico con un procinetico y un antisecretor que generalmente es eficaz. Las indicaciones de cirugia suelen ser excepcionales en el nino.

Resume Chez l’enfant, la sarcoidose est rare et peut revetir des aspects trompeurs. Les auteurs rapportent l’observation d’un enfant âge de 13 ans explore pour une fievre prolongee, un syndrome inflammatoire et des lesions cutanees. L’echographie abdominale a montre une hepatomegalie, des adenopathies mesenteriques et un nodule splenique. Le scanner thoracique a visualise des adenopathies hilaires bilaterales. La biopsie d’une adenopathie inguinale a conclu a une tuberculose caseofolliculaire. L’echec du traitement antituberculeux, la fievre elevee, la negativite de l’intradermoreaction a la tuberculine et les resultats de la biopsie cutanee ont fait suspecter le diagnostic de sarcoidose. Celui-ci a ete conforte par les resultats du lavage broncho-alveolaire, le taux eleve de l’enzyme de conversion de l’angiotensine et le controle de l’examen anatomopathologique. L’evolution sous corticotherapie a forte dose a ete favorable. La sarcoidose, meme si elle est rare chez l’enfant, doit etre evoquee devant une fievre prolongee et un syndrome inflammatoire important.

Apesar de las expectativas suscitadas por la disminucion regular de la morbilidad y de la mortalidad causadas por la tuberculosis, los datos epidemiologicos recientes muestran que esta enfermedad dista de haber sido erradicada. Varios factores contribuyen al resurgimiento actual de la tuberculosis, en particular las condiciones socioeconomicas dificiles y la infeccion por el virus de inmunodeficiencia humana. A principios del siglo XXI, la tuberculosis no ha perdido actualidad y la lucha contra esta enfermedad sigue siendo una prioridad. Esta lucha se basa en la deteccion precoz y el tratamiento de los enfermos, sobre todo los enfermos contagiosos, y en la vacunacion BCG (bacilo de Calmette-Guerin). La vacunacion tiene por objetivo principal proteger a los ninos pequenos de las formas graves de tuberculosis, en particular la meningitis tuberculosa y la tuberculosis miliar.

Progression of pulmonary sarcoidosis in children remains poorly documented. The aim of this work was to gather follow-up information on pulmonary outcomes in children with sarcoidosis and to obtain data of relevance to a discussion of the optimal length and regimen of glucocorticoid therapy.In the present study, the authors experience of pulmonary sarcoidosis in 21 children referred to the paediatric pulmonary department over a 10-yr period is reported with a documented follow-up of at least 4 yr. Evaluation of the disease during the follow-up included analysis of clinical manifestations, chest radiographs, pulmonary function tests with measurements of the vital capacity (VC), dynamic lung compliance (CL,dyn), lung transfer for CO (TL,CO), and arterial blood gases, as well as bronchoalveolar lavage (BAL) with determination of total and differential cell counts.After initial evaluation the decision was a careful observation of four children without therapy. Corticosteroid treatment was initiated in 17 children. Analysis of results indicated that after 6–12 months of treatment most clinical manifestations of the disease and chest radiograph abnormalities disappeared, and beneficial effects on VC andTL,COwere apparent. After 18 months of steroids no benefit on pulmonary function tests could be noticed, with mainly persistence of alterations ofCL,dyn. Results of BAL studies documented the presence of an alveolitis with increased lymphocyte populations throughout the follow-up. Relapses were observed in four children during tapering of prednisone; they were not reported after discontinuation of steroid therapy.Taken together data obtained in the presented population can lead to the following suggestions for the management of pulmonary sarcoidosis in children. BAL should be performed at the initial evaluation to document alveolitis; however, nothing seems to be gained from repeating this investigation during follow-up in the absence of specific reasons. Once the decision to initiate glucocorticoid therapy is made, 18 months may be a reasonable treatment duration. Discontinuation of therapy can be decided even if the pulmonary function tests remain abnormal, but the child should then be carefully monitored for a relapse.

Resume Observation Nous rapportons le cas d'un adolescent ayant eu une tuberculose disseminee revelee par une otite chronique. Les investigations ont mis en evidence une atteinte de l'oreille moyenne et des lesions pulmonaire, ganglionnaire, osseuse. Sous traitement, l'evolution a ete marquee par une surdite sequellaire. Conclusion La tuberculose de l'oreille moyenne doit etre evoquee devant une otite chronique et des facteurs de risque de tuberculose. La recherche d'une dissemination doit etre systematique et le traitement precoce afin d'eviter des sequelles auditives.

Study objective The development of BAL in children for both research and clinical purposes has been limited so far by the difficulty in establishing reference values. The aim of the study was (1) to define composition of BAL cellular components in control children and to evaluate the ability of these cells to express various cytokines, and (2) to study modifications of differential cytology and BAL cell cytokine responses in children with interstitial lung disorders. Populations and methods Two groups were investigated: a control group of 16 children who were concluded to be free of parenchymal lung disease after complete pulmonary investigation, and a group of 11 children with pulmonary sarcoidosis. Differential cytology was evaluated by standard techniques. BAL cell cytokine expression was studied at the level of messenger RNA (mRNA) by reverse transcription-polymerase chain reaction (RT-PCR) methods. Results In the control group, differential cell counts appeared to be similar to values reported in adult populations with normal distribution of the data and no influence of age. In this group, no transcripts for interleukin-1β (IL-lβ), tumor necrosis factor-a (TNF-a), IL-6, and tranforming growth factor-β (TGF-P) could be detected. In children with sarcoidosis, different profiles of IL-1β, TNF-α, IL-6, and TGF- β expression were individualized which seemed to be related to the activity and/or severity of the disease, IL-6 and TGF-β mRNA being observed only in the more severe forms. Conclusion These data provide information on BAL cell number and function in children. Characterization of BAL cytokine expression patterns during the course of interstitial lung diseases in children may be of great interest for evaluation of disease activity and/or severity and therefore for planning of therapy.

Bronchodual is a combination of two bronchodilators, a beta-2 adrenergic substance (fenoterol, 50 micrograms per dose), and an anticholinergic substance (ipratropium bromide, 20 micrograms per dose), administered by metered aerosol. According to different studies carried out with adults and children, the bronchodilating action of this combination is greatly superior to that obtained with each substance individually; the beta-2 adrenergic substance can be spared; its action is longer and involves a decrease in the number of drug intake and lastly its tolerance is excellent. A French multicentre study was performed with 74 children (7 to 15 years old, mean: 11.8 +/- 2.6 years), 53 boys and 21 girls with allergic or non-allergic asthma: 41 children presented a moderate asthma (one crisis per month) and 33 children moderately severe asthma (one crisis per week). These children had been given no corticosteroid therapy (per os or inhaled) for at least 15 days, their usual long-term treatment (cromoglycate, anti H1, theophylline LP, antibiotics) was given as normal. Their FVC was > or = 80% of predicted values and they presented an intercritical airway obstruction. Hypoxemia was noted in 41.2% of the children. A reversibility test was performed with Bronchodual: 68 of 74 children (i.e. 91.9%) were responders, ie after two doses of Bronchodual at least one of the FEFs had increased by at least 15% when compared with the initial values. The responders were given a 2 month treatment with two inhalations 3 times/day with a spacer. Fifty-seven patients were considered for the final evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective To evaluate the sensitivity of multidetector computed tomography for confirming suspected foreign body aspiration into the airways in children. Method We conducted a multicentre prospective study of 303 children evaluated using multidetector computed tomography with axial analysis complemented by multiplanar reconstruction when required. The images were read by a radiologist before endoscopy then reviewed later by a senior radiologist blinded to the endoscopy findings. Endoscopy was performed routinely. Results Foreign bodies were found by endoscopy in 70 of the 303 children. The initial multidetector computed tomography reading was 94% sensitive and 95% specific. For the review, the images for 91 patients were excluded because of motion blurring or absence of larynx visualisation; in the remaining 212 patients, sensitivity was 98% and specificity 97%. Conclusion Multidetector computed tomography as performed in our patients cannot replace endoscopy, which remains the reference standard. Nevertheless, multidetector computed tomography is sufficiently sensitive to be of value when foreign body aspiration is not considered initially or when endoscopy is likely to prove challenging.

Sarcoidosis is a multisystemic granulomatosis of unknown etiology which mainly affects young adults. It is characterized primarily by bilateral hilar adenopathies, a pulmonary infiltrate and cutaneous and ocular lesions. It rarely occurs in children under the age of 16. Localization in the upper respiratory tract (URT) is infrequent and sarcoidosis of the URT in children is exceptional, with only 13 cases reported in the literature. In the present report we describe the clinical, diagnostic explorations, histological and therapeutic aspects of 2 new cases in children.

Resume Le but du travail a ete de realiser une etude prospective, dans une grande creche collective (GCC) de 93 enfants âges de 3 a 36 mois, de la bronchiolite (BO) et des facteurs de risque associes : tabagisme parental, antecedents allergiques familiaux, presence d'animaux familiers. La BO est frequente avant l'âge de 2 ans : 20 cas sur 61 (32,8 % des cas), 6 nourrissons (N) sur 20 (33 %) ont contracte leur premiere BO moins de 3 mois apres l'entree a la creche, 6 sur 20 sont âges de moins de 6 mois lors de la premiere BO. Etant donne la frequence et la periodicite de la BO chez les N frequentant une GCC, des mesures preventives indispensables sont proposees : lavage des mains du personnel, des tables de change, pas d'admission de N de moins de 6 mois de septembre a janvier, surtout s'ils sont issus de parents asthmatiques. Le tabagisme parental favorise surtout la repetition des BO.

We analysed retrospectively 11 children with renal granulomatous sarcoidosis confirmed by renal histology in order to describe the course and prognosis of the disease. Symptomatic sarcoidosis was diagnosed at a mean age of 10.1 years. Nine children had renal involvement at the time of diagnosis. In the course of the disease, nine patients developed renal failure and mild proteinuria, seven had transient sterile leucocyturia, four showed microscopic haematuria, seven had a urinary concentrating defect, and enlarged kidneys were seen in three patients. One child had hypercalcaemia and hypercalciuria, none had hypertension. Light microscopy of the kidney showed interstitial infiltration by mononuclear cells in all children, interstitial fibrosis in nine patients, epithelioid granulomas in seven, tubular involvement in eight, and mild glomerular involvement in seven patients. Renal immunofluorescence was negative. Ten children received prednisone for 1–11 years. After a mean follow up of 5.5 years, three patients had entered end-stage renal failure and one had chronic insufficiency after interruption of medical supervision and prednisone therapy. Conclusion Renal failure, proteinuria, leucocyturia, haematuria, and concentration defect are the prominent features of renal granulomatous sarcoidosis in children. Steroid therapy, adjusted according to disease activity, may prevent end-stage renal failure.

The development of BAL in children for both research and clinical purposes has been limited so far by the difficulty in establishing reference values. The aim of the study was (1) to define composition of BAL cellular components in control children and to evaluate the ability of these cells to express various cytokines, and (2) to study modifications of differential cytology and BAL cell cytokine responses in children with interstitial lung disorders.Two groups were investigated: a control group of 16 children who were concluded to be free of parenchymal lung disease after complete pulmonary investigation, and a group of 11 children with pulmonary sarcoidosis. Differential cytology was evaluated by standard techniques. BAL cell cytokine expression was studied at the level of messenger RNA (mRNA) by reverse transcription-polymerase chain reaction (RT-PCR) methods.In the control group, differential cell counts appeared to be similar to values reported in adult populations with normal distribution of the data and no influence of age. In this group, no transcripts for interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), IL-6, and transforming (correction of tranforming) growth factor-beta (TGF-beta) could be detected. In children with sarcoidosis, different profiles of IL-1beta, TNF-alpha, IL-6, and TGF-beta expression were individualized which seemed to be related to the activity and/or severity of the disease, IL-6 and TGF-beta mRNA being observed only in the more severe forms.These data provide information on BAL cell number and function in children. Characterization of BAL cytokine expression patterns during the course of interstitial lung diseases in children may be of great interest for evaluation of disease activity and/or severity and therefore for planning of therapy.

Right pneumonectomy can lead to severe respiratory impairment due to stenosis of the left main bronchus. This syndrome is usually treated by inserting a fixed-volume prosthesis but, in children, expandable prostheses have the advantage of being adaptable to growth and permit progressive recentering of the mediastinum. We report 3 such cases, with the results of pulmonary function tests. The patients were aged 11, 17, and 22 years at the time of implantation and had undergone pneumonectomy during childhood for either bronchiectasis or complete pulmonary sequestration. All 3 patients are doing well, with a follow-up of 1 to 3 1 2 years. Pulmonary function tests have shown a substantial improvement in the obstructive syndrome in 2 patients whereas, in the third patient, in whom the contralateral lung was not perfectly healthy, the functional improvement was only moderate.

The clinical course of sarcoidosis in children has not been well defined. Eight children with symptomatic sarcoidosis included in this study underwent pulmonary function tests and bronchoscopy with bronchoalveolar lavage (BAL) before treatment and during steroid therapy. At the start of therapy, functional parameters, mostly dynamic lung compliance and lung transfer factor for CO, were impaired. This was associated with abnormalities of BAL cell populations: increased total cell number with a high proportion of lymphocytes, modifications of lymphocyte subpopulation with an elevated CD4+/CD8+ ratio, and enhanced ability of alveolar macrophages to release hydrogen peroxide. Although respiratory abnormalities seemed to be similar at the initial stage of sarcoidosis in children and adults, the course of the disease appeared to be different. Despite the absence of respiratory symptoms and disappearance of chest radiographic abnormalities on prolonged steroid treatment, we found slow improvement of pulmonary functions associated with persistence of BAL lymphocytosis and elevated CD4+/CD8+ ratios. However, the ability of alveolar macrophages to release hydrogen peroxide was significantly reduced after 6 months of steroid treatment, and it remained identical to the control group. Therefore, the evaluation of disease activity appears to be critical for therapy in pediatrics, and for this purpose studies of alveolar macrophage activation may be of particular interest. Pediatr Pulmonol. 1993; 16:41–47. © 1993 Wiley-Liss, Inc.

Background. Ciliary ultrastructural defects with total lack of dynein arms (DA) cause abnormal mucociliary function leading to the chronic infections observed in primary ciliary dyskinesia. The role of partial ciliary ultrastructural defects, especially those involving the central complex, and their relationship with respiratory symptoms have been less thoroughly investigated. Objective. In a pediatric population with partial ciliary defects, we determined the relationship(s) between ultrastructural findings, ciliary motility, and clinical and functional features, and evaluated the outcome of this population. Design. We analyzed the clinical presentation and pulmonary function of 43 children with chronic bronchitis and partial ultrastructural defects (from 15% to 90%) of their respiratory cilia demonstrated on bronchial biopsies. The study population was divided into 3 groups according to ciliary ultrastructure: the main ultrastructural defect concerned the central complex in 23 patients (CC group), peripheral microtubules in 8 patients (PMT group), and DA in 12 patients (DA group). Results. The percentage of ciliary defects was lower in the PMT group than in the CC and DA groups. Patients in the PMT group had less severe disease with frequent normal ciliary motility. Patients in the CC group had initially a higher incidence of respiratory tract infections, extensive bronchiectasis frequently requiring surgery, and arguments in favor of a congenital origin (high proportion of sibling form). Partial absence of DA, although of congenital origin, was associated with a good prognosis. In all groups, follow-up showed that the functional prognosis remained good with appropriate treatment. Conclusions. In children with chronic respiratory infections, presence of situs inversus, sibling form, obstructive pulmonary syndrome, or bronchiectasis required ultrastructural analysis, regardless of ciliary motility. Detection of CC abnormalities is a marker of severity and required intensive therapy and close follow-up.

Summary A longitudinal study has been conducted on 114 children in a hospital for primary tuberculosis, in order to determine the incidence of Group A latent streptococcal infection. The subjects were regularly examined for the presence of Group A streptococcus in the throat, the level of streptococcal antibodies in the sera; a daily methodical investigation was also performed in the search of any clinical symptoms of infection. The analysis of the modes of infection shows that several degrees exist between the subject remaining free of any contact with group A streptococcus and that one who presents a clinically acute infection; some children are truly healthy carriers, but more frequently the acquisition of the germ is followed by a rise of serological reactions. This infection may be clinically latent, 01: may show Clinical Symptoms of disease. Children classified as chronic carriers may harbour a single type of streptococcus or two or more types which may or may not be present concurrently within the carrier.

The control of breathing at rest was studied in 30 children (3 to 17 years old) with chronic obstructive pulmonary disease (COPD). Five of them were tested several times during the follow-up of the COPD. Breathing pattern was evaluated and mouth occlusion pressure (PO.1) was measured. Results in COPD children were compared to previously reported values in healthy controls. PO.1 was significantly increased. In 11 children breathing O2, PO.1 decreased but remained at higher levels than predicted. However, the decrease in PO.1 in COPD was not significantly greater than in healthy children. These results may be explained by the relative mild hypoxemia in those children. The increase in PO.1 was significantly correlated with the increase in lung resistance (p less than 0.02) and with the decrease in dynamic lung compliance (p less than 0.01). Most of the COPD children were normocapnic. However, modifications in the breathing pattern were observed. The inspiratory time (TI) was significantly shortened, the expiratory time was prolonged and the TI over the total duration of the respiratory cycle was lowered. The respiratory frequency was unchanged. The tidal volume, normalized for body weight (VTBW), was increased. The mean inspiratory flow (VTBW/TI) was significantly augmented, but not as much as PO.1: in consequence, the effective inspiratory impedance was higher than predicted. Thus, as adults, COPD children had a greater inspiratory neural drive. In contrast to normocapnic COPD adults, they had a modified respiratory timing.

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THE ADVERSE effect of corticosteroids has been demonstrated experimentally in tuberculous animals. 7,20,28,30,44 However, the dosage in these experiments was high, about ten times the amount currently used in human beings. Other experiments, in which there was a smaller dose of steroids associated with specific antituberculosis drugs have demonstrated the favorable effect of hormonotherapy on exudative lesions in laboratory animals. 2,4,33 In tuberculous lymph nodes, steroids reduce both necrosis and the formation of epithelioid cells and exert an inhibitory effect on fibrosis. 24 In clinical medicine, the deleterious effect of steroid treatment on tuberculous lesions has also been observed, 4,10 but here also the combination of steroid treatment with effective antituberculosis chemotherapy gives excellent results in certain selected cases. 1,5,9 It was first claimed to be effective in pleural effusions 40 and the claim then extended to some other forms of human tuberculosis. 3 Favorable effects were confirmed by pathologic